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Ethics sign
by Athena Motal, PhD, LCSW-R
Understanding ethics in social work isn’t as simple as taking a class and learning everything you need to know. In fact, thinking back to my social work research class in 1985, we didn’t even talk about ethics. The professor gave us each a copy of the NASW Code of Ethics pamphlet, which I tucked into my notebook. That was it.
As I read the pamphlet later, I was drawn to the six core values of the profession: Service, Social Justice, Dignity and Worth of the Person, Importance of Human Relationships, Integrity, and Competence. I viewed these as the canons of the profession, but at such an early stage of my learning, I couldn’t truly connect with them—or what they would come to mean in the service of others.
After I transitioned to hospital social work, I often found myself involved in resolving tense and complicated patient-family situations. It was only then that I truly began to understand those core values, and it took a combination of education and real-world experience to feel as if I had mastered how to apply them. As you move forward on your own journey of understanding in relation to ethics, I hope my journey will help you, too.
Meet Maria
One of the earliest cases of my career was that of Maria. A 45-year-old female who was homeless and living in a cardboard box by the Brooklyn Queens Expressway (per the EMS report), Maria was found unresponsive and brought to a New York City public hospital emergency room with weathered skin and raw hands and feet. She was in the ICU for three weeks with cirrhosis of the liver, secondary to ETOH; insulin dependent diabetes; and legal blindness. Maria was originally from Czechoslovakia and did not speak English. She also was undocumented and had no family, source of income, or benefits.
As her health status improved and she became medically ready for discharge, she transferred to my unit. To prepare for her release, I researched and developed the safest and most appropriate plan, which included connecting Maria with a medical shelter where she would receive a diabetic diet and charity assistance with her insulin injections. I also planned to arrange transportation, a new set of clothes and sneakers, and insulin supplies.
My Best Laid Plans and Best Intentions
When I went to meet with Maria and talk about the plan via an interpreter, she graciously declined everything I offered, but had no alternative as to where she would go or what she would do. We were in the midst of a major nor’easter, and we could hear the winds gusting through the window. Clearing her to leave knowing she was bound for the streets or a cardboard box was not consistent with what I perceived to be best for her safety and well-being, so I stalled and hoped she would change her mind.
Day after day, Maria perched at the edge of her bed, patiently waiting to be discharged. Little did she know that she was at the mercy of an inexperienced social worker! I went to my supervisor, who was not able to offer direction. This outcome rested on my shoulders, and I feared that if I socially cleared her for discharge, it would almost certainly cause her harm and place her in danger.
Respecting the Patient’s Rights
What I really needed to know was: Did Maria fully understand the risks of leaving the hospital without service and what the implications of that choice might be? After consulting with the medical team, which formally submitted an order on my behalf for the psychiatric consultation liaison service, I spoke with the attending psychiatrist and explained my conundrum. A thorough 90-minute evaluation was conducted, which determined that Maria’s blindness and diabetes were chronic factors that would not cause immediate harm upon discharge. Maria had the right to leave and go wherever she wanted.
My fight was over, and there was no more persuasion to be done. I encouraged Maria to wait until morning to leave, but she wanted to go immediately—in the height of the storm. I spoke with the nurse, and we gathered supplies, including a fresh set of clothes and sneakers to replace what had been soiled in the emergency room, as well as small juices and snacks. I also created a list of drop-in shelters and food pantries and scheduled her follow-up appointments. The nurse and I went in together, and Maria cried with gratitude, getting down on her knees to say “thank you.” At 9:00 p.m., she was escorted to the lobby.
The Big Picture Comes Into Focus
In the lobby, a man from her homeless community was waiting, eager for her to be discharged. Two weeks later, this gentleman returned with daisies and placed them in front of me. He could not speak English but clasped his palms together and bowed—his way of saying “thank you” that Maria had been returned to those who loved her.
This case stayed with me for a very long time. While I appreciated the education from the psychiatrist, I wondered why I hadn’t been able to recognize Maria’s right to leave sooner. What she needed felt so clear to me, and I felt duty-bound to keep her safe, but my plan for her may not have been what she needed at all. As I looked back on Maria’s case over the years, it was always with the residue of moral distress and the feeling that I may have caused her harm.
Deeper Knowledge and Deeper Understanding
Years later, in 2008, I took a year-long required course called “Ideology” as part of my PhD in Social Work program. Within the course was the study of values and ethics, and our professor introduced us to scholars like Charles Levy, Frederic Reamer, and Marian Mattison, just to name a few. We also learned about ethical theories, covering topics like values and knowledge, conflicts between personal and professional values, identifying ethical dilemmas, and many others.
We read a seminal book by our professor, Dr. Norman Linzer, titled Resolving Ethical Dilemmas in Social Work Practice. Dr. Linzer was also a rabbi and an ethics expert, and his book was filled with real cases that illustrated the identification and resolution of these kinds of dilemmas. As I immersed myself in reading, a weight lifted from my mind and I started to connect the dots.
I realized that the problems I’d perceived previously were actually ethical dilemmas that I was not able to resolve effectively because I was using a problem-solving approach. Now, approaching these problems from a perspective informed by both my experience and the literature I’d studied, I was able to relive some of my more complex cases and center them through either Reamer’s or Mattison’s ethical decision-making models. It all began to come together and make sense.
Revisiting Maria
The principles of biomedical ethics transcend all professions. Looking back at Maria’s case, I can see I was trying to uphold two principles: the principle of beneficence to do good for her benefit, and the principle of non-maleficence to avoid harm. However, Maria was trying to protect her right to self-determination.
Putting it in the context of the six core values of social work, the most important value I was trying to uphold was to provide the best possible service according to my level of competence. Unfortunately, upholding this value of service violated Maria’s right to exercise her autonomy. That left me feeling locked in the horns of an ethical dilemma. My value and Maria’s value were both valid, but only one could prevail. Ultimately, Maria’s right to make her own decision superseded mine, even if it went against my professional and personal value systems.
The Journey Continues
Social work is an ethics-based profession grounded in the six core values and 82 principles. It took me 23 years from the time I completed graduate school to feel as if I understood the world of values and ethics, and it took a combination of knowledge acquired through real world experiences and the study of ethical theories and decision-making models for me to get there.
My doctoral qualitative research was a multiple case study on how social workers resolve ethical dilemmas without formal education in ethics, and I promised myself (and the profession) that if I were ever privileged to teach Values and Ethics, my students would be more informed and competent in ethics than I was. Now that I’m teaching Values and Ethics, I strive to uphold that promise every day.
As you navigate your own journey of ethical understanding, don’t be afraid to look back at cases from your past, read the scholarly literature, and apply the subsequent knowledge you’ve gained. Reflecting on old experiences with a new perspective opens up the potential for new insights to be revealed and also provides opportunities to strengthen your understanding of the six core values and your ability to apply them in ways that benefit and serve your clients.
Dr. Athena Motal
A member of the NASW National Ethics Committee, Athena Motal, PhD, LCSW-R, has had a rich and rewarding social work career in health and human services within New York City’s public and private hospital systems, serving vulnerable populations experiencing acute and chronic medical and mental health conditions. She is an adjunct professor and Director of Social Work Recruitment, Outreach, and Enrollment at Touro University Graduate School of Social Work.